<!-- form payment -->
      <div class="col-sm-6 m-t">
      <h4><strong>Please provide your information!</strong></h4>
		  <form method="post" action="#fake" data-validate="parsley">
                    <section class="panel panel-default">
                      <header class="panel-heading">
                        <span class="h4">Form</span>
                      </header>
                      <div class="panel-body">
                        <p class="text-danger">* please fill the fields below.</p>                        
                          <div class="form-group pull-in clearfix">
                            <div class="col-sm-6">
                              <label>Full name</label>
                              <input type="text" class="form-control" placeholder="Enter full name" data-required="true">
                            </div>
                            <div class="col-sm-6">
                              <label>Age</label>
                              <input type="text" class="form-control" placeholder="Enter age" data-required="true">
                            </div>
                          </div>
                          <div class="form-group">
                            <label>Phone No</label>
                            <input type="text" data-required="true" class="form-control" placeholder="Enter phone number">
                          </div>
						               <div class="form-group">
                            <label>Ocupation</label>
                            <input type="text" data-type="url"  data-required="true" class="form-control" placeholder="Enter ocupation">
                          </div>
                          <div class="form-group">
                            <label>Address</label>
                            <textarea class="form-control" rows="3" data-minwords="3" data-required="true" placeholder="Type your address"></textarea>
                          </div>
                      </div>
                      <footer class="panel-footer text-right bg-light lter">
                        <button type="submit" class="btn btn-success btn-s-xs">Ok</button>
                        <button type="submit" class="btn btn-danger btn-s-xs">Exit</button>
                      </footer>
                    </section>
                  </form>
      </div>
	   <!-- END form payment -->
